Healthcare Provider Details

I. General information

NPI: 1811262272
Provider Name (Legal Business Name): CELLNETIX PATHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 5TH AVE
SPOKANE WA
99204-2803
US

IV. Provider business mailing address

1124 COLUMBIA ST SUITE 200
SEATTLE WA
98104-2026
US

V. Phone/Fax

Practice location:
  • Phone: 866-236-8296
  • Fax:
Mailing address:
  • Phone: 866-236-8296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN RANDY BOREK
Title or Position: CFO
Credential:
Phone: 206-576-6138